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FOR OFFICE USE: ------ ---- ------ -. ---- �' APPLICATION FOR SANITATION PERMIT Permit No. ------------------------------------------- ------- -- (Complete in Duplicate) This Permit Expires ] Year From Date Issued Date issued Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549. JOB ADDRESS AND LOCA�TION__Ccr'1m -c-- - cc.' ---- - ------- �r. --- ----------------------------------------- Owner's Name_r .,__... fr1rG_ -------------------------------------------------------------------------------- ----------- Phone--------------------------------- Address------------- •� Contractor �f 75: ` Contractor's Name = R------------------------------------------------ ---•--------- ------------------ Phone----------------------------------- Installation will serve: Residence [A�-Aparfinent House ❑ Commercial ❑ Trailer Court ❑ Motel ❑ Other ❑ Number of living units: ___-I_._ Number of bedrooms 3---- Number of baths -_(---_ Lot size ______________________________ Water Supply: Public system ❑ Community system ❑ Private [Depth to Water Table _/4- ft. Character of soil to a depth of 3 feet: Sand [] Gravel ❑ Sandy Loam lay Loam ❑ Clay ❑ Adobe ❑ Hardpan [] Previous Application Made: (If yes,date------ -----------) No New Construction: Yes gR--1-o ❑ FHA/VA: Yes ❑ No Er-�•� TYPE OF INSTALLATION AND SPECIFICATIONS: .� (No septic tank or cesspool permitted if public sewer is available within 200 feet.) .� Septic Tank- _Distance from nearest well�� ____._ Distance from foundation-_-�Q�_ ._-_.--.Materiel____.________--- ------------ ------------------- �Q [� No. of compartments-- -------------------Size-_�r:t`ac_s_�_`L-----Liquid depth----' --------------Capacity___./k0g___4 Disposal Field: Distance from nearest well-+sem_.......Distance from foundation__eo------------Distance to nearest lot line__-.`--_____ Number of lines.___s'L.___------------------------Length of each line___96_------------------Width of trench-- -4__.f_____..._---_------ Type of filter material-__/ oak----------Depth of filter material_-1B'__j__________--Total length------- O_'________________________ O Seepage Pit: Distance to nearest well----------------------Distance from foundation--------------------Distance to nearest lot line--.-----.--_----. ❑ Number of pits----------------------Lining material----------.------------Size: Diameter-----------------------Depth-----------------_----------_---- s Cesspool: Distance from nearest well-----------------Distance from foundation....................Lining material___.__-..___-----------__._________. A ❑ Size: Diameter--------------------------- ----- ----Depth----------------------------------------------------Liquid Capacity----------------------------gals. 7 Privy: Distance from nearest well---------------------------------------__._.._._Distance from nearest building_____-__-----------_____-____.__..____._. �1 ❑ Distance to nearest lot line.--------------------------------- - - ----- - ------------------•--------------------------------------------------------------------------- i Remodeling and/or repairing (describe):-- ------ --------------------------- ---------------------------------------------------------- -------------- ----------------------------------------- ------------------------- ----------------------------------------------------•--•------------------------------------------------------------------------------------------------------------------------ D ------------ ---------------------------- ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, S:fa e�I,and r s d regul ions of the San Joaquin Local Health District. (Signed)---------G-----.---- = - ---- ---------------- ------ -------------------------------- --------- --------------------------(Owner and/or Contractor) B (Title)_ (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc., can be placed on reverse side). 11 FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY--- -4- C-- —------------------------------------- - DATE � - f�-�-�'--------- --------------------- ------------------ REVIEWEDBY---------------------------------- -------------------------------------------------------- DATE BUILDINGPERMIT ISSUED---------------- ------------------------------------- --------------------------------------------- DATE----------------------------------------------------- / - -- c,` �---� I --------- Alterations and or recommendations:- - - --- - -- --- -----------------------------------------------------------------------------------------------------------I---------------------:------------------------------------------------------------------------------------------- ------------------------------------ ------------------- ----- - --- ------------------------------------------------------------------------------------------------------- ----------- ----------------- ---------------------------------- --------- -------------------------------------------------------------------•--•-------------------------------------- ----- ------------------ 0 FINAL INSPECTION BY: ------------------------------------- --- Date.........;;,2. /...' !----------------------------------- SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E.Hazeltan Ave. 300 West Oak Street 124 Sycamore Street 205 West 9th Street Stockton,California Lodi,California Manteca,California Tracy,California F.P.CO.